Social determinants, including racism, are major drivers of health inequality, says Watson

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The social determinants of health (SDOH) are major drivers of observed inequalities in health outcomes, and racism is clearly a social determinant linked to life expectancy, said Karol Watson, MD, PhD, during a a talk Sunday at the 2022 Congress of the American Society for Preventive Cardiology, held in Louisville, Kentucky.

The social determinants of health (SDOH) are major drivers of observed inequalities in health outcomes, and racism is clearly a social determinant linked to life expectancy, said Karol Watson, MD, PhD, during a a talk Sunday at the 2022 Congress of the American Society for Preventive Cardiology, held in Louisville, Kentucky.

Watson, a professor of medicine/cardiology at UCLA’s David Geffen School of Medicine, began with data that has helped fuel the conversation about SDOH across all medical specialties: the outsized effect on mortality that the pandemic of COVID-19 has had on people of color.

“Just as the rich seem to be getting richer and the poor seem to be getting poorer, so has life expectancy lost during the pandemic.”

In 2018, she said, the overall life expectancy for men was 78.8 years, although there were disparities by race. In 2020, at the height of the pandemic, the overall life expectancy for men had fallen to 75.1 years, but for black men it fell to 68.3.

“That’s 3 years after you hit Medicare age, that’s probably around the time you have your first grandchild,” Watson said. “This is shocking and unacceptable.”

These racial differences in outcomes occur, she said, even though genetically the difference between the races is barely detectable – there is only about 0.1% difference in DNA.

“Race is a social construct, not based on biology or genetics,” Watson said. On the contrary, “race refers to a group of people who generally share certain physical characteristics”. Ethnicity refers to a group of people who share a culture; Watson said race refers to how people look, while ethnicity refers to how people live.

And yet, because of racism, many characteristics related to life expectancy segregate along racial lines. “So it’s not an entirely unnecessary social construct,” Watson said.

She pointed to the influence of Swedish botanist Carl Linnaeus, called the “father of modern taxonomy” for his work categorizing plants, animals and, later, humans. Except, his fairly racist descriptions of different races. Whites, Watson explained, were “soft and inventive”, while blacks were “impassive and lazy”.

“That’s where we get our groceries,” she said. “It started with racism.”

With Wendy Post, MD, MS, of Johns Hopkins as first author, Watson just published the results in Traffic which show that black participants in the MESA study had a 34% higher risk of all-cause mortality and cardiovascular disease. “Obviously we see differences in life expectancy.”

In this study, she and Post controlled for SDOH factors, which eliminated some, but not all, of the differences.

Watson saw the effects firsthand. She described a patient who had just been discharged after uncomplicated STEMI. He received dietary advice; doctors made sure he was given generic prescriptions and he was booked for cardio rehabilitation. But at the patient’s next appointment, he said he struggled to pay for the drugs, which cost $5 to $8 a month. And because he had 2 jobs, 1 of which was on the weekends, he missed rehab visits.

She described the frustration of seeing patients come to the clinic with McDonald’s bags. “None of us like to see that.” But a patient told him it was the breakfast he could afford and the Wi-Fi was free.

“We need to understand that social determinants matter more than so many other things to many of our patients,” Watson said.

There are many modifiable factors that influence health, but income trumps many others. She pointed to the famous Whitehall study of British civil servants, which compared mortality across social classes. The assumption that senior executives would have worse mortality turned out to be completely wrong; lower-ranked workers fare the worst.

“The impact of the social benefit on health is considerable,” she said. There is a 14-year difference in cardiovascular mortality in different parts of the country based on socioeconomic differences.

And as difficult as it is to measure, “We can’t forget racism.”

Acts that are overly racist are easy to recognize, she said. But unconscious biases are not – and structural racism is “almost invisible”.

The social determinants of health, she said, begin at birth and exist as people grow, work and age, and need to be addressed. “Health differences are health differences,” Watson said. “Health inequalities are those that are unfair and unjust.”

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